Health Insurance Fund (Shifa)

Health Insurance Fund (Shifa)

The Bahrain Health Plan 2016-2025 lays the foundation for the development of health services, by providing high-quality and sustainable health services and ensuring a sufficient number of human resources and infrastructure to achieve the goals of the Bahrain 2030 vision.

The plan involves creating the Health Guarantee Fund (Shifa) to improve the quality and sustainability of health services. This will support the health system by utilizing its resources better and dealing with the existing challenges such as the increase in population, aging population and the resulting strain on health services.

The new system will give birth to "Shifa," an independent institution with a legal entity headed by a state-appointed board of directors."

Some of the main tasks of the Health Guarantee Fund (Shifa) are:

• Designing the payment model.

• Designing the benefits package.

• Population analysis and management.

• Quality

• Drugs and technology management.

• Communication and connection.

• Resource collection

• Work network.

• Pricing and volume negotiation.

• Claims management and handling.

• Fraud detection and risk management.

• Actuarial analysis.


The fund provides the following insurance coverage:

Mandatory package for citizens is funded by the state and covers medical treatment at government facilities.

Foreign residents are covered under the mandatory package either directly or through insurance companies. Additional services can be purchased if desired.

Optional package with a shared participation of 40% from the participant and 60% from the government, in addition to participant's payment of bills for treatment at public and private healthcare facilities.

The vision

To provide comprehensive healthcare for all, with a patient-centered focus on continuous improvement and development.

The mission

To provide high-quality, sustainable and fair health services with high efficiency, compared to the best global standards, as an independent public institution.

The strategy for the Health Insurance Fund (Shifa) can be summarized as follows:

• To be an active buyer

• Supporting patient freedom in choosing healthcare providers

• Controlling costs and facilitating service delivery

• Implementing cost sharing for healthcare benefits, excluding mandatory package for citizens

• Adopting a DRG system for inpatients and a capitation system for primary care

• Providing basic health benefits with a high positive package, excluding cosmetic services

• Establishing quality criteria within service contracts

• Collaborating with the Ministry of Health on community health programs

• Setting a budget cap for service providers

• Applying the health insurance to visitors

• Knowing the cost of service providers and pricing based on hospital costs by level

• Working with a single TPA for Shifa and mandatory package for residents.

Diagnostic Related Groups (DRG) system

It is used for inpatient hospital treatment services and aims to transfer risk to the service provider by determining a single cost of the case based on diagnosis, gender, age, and health status of the patient.

Foundations of the System:

  • Identify the average cost value in hospitals to determine the average cost value in Bahrain.
  • Adopting the relative weight for groups based on the Australian system.
  • Calculating the patient's cost upon discharge from the hospital = average cost × relative weight for the group with consideration of age, gender, and accompanying diseases to determine the final price within the group.


  • Adopting a unified payment system between service providers and buyers to work within a unified framework.
  • Adopting agreed upon terminologies and standard definitions and standard data groups for (M-T) to determine the size of work and, thus, expenses.
  • Training medical personnel on completing medical information in the medical file according to the requirements of the system.
  • Training coders to prepare claims.
  • The readiness of the Salmaniya RCM accounting department and other hospitals to review claims and send them to the service buyer.
  • Organizing workshops to train workers in Salmaniya.
  • The Directorate of Health Economics is responsible for implementing and monitoring the system.

Inpatient Processing System

The main objectives of the system:

 An appropriate and acceptable health insurance program for beneficiaries and business owners, based on a central database that ensures effective and high-quality health services. The first phase strategic plan (two years from the start of implementation)

First: The Mandatory Package

The market is dealt with minimal intervention, to study the situation and interact with all components of the system to benefit from it for designing future steps.

The market will start with open to all insurance companies and TPA companies.

Registration: Responsibility of the business owner, and it is mandatory for all workers and those who support them in any registered insurance company in the system.

Insurance companies must deal with NHIIS to pass claims with service providers, without any requirements for medical examination for insurance during the first period. The insurance market sets its prices based on their experience in the market and their commitment to the mandatory packages, within the highest and lowest limit of the specified subscription determined by the Supreme Health Council.

During the first period, the mandatory health package is designed with limited benefits while following the law to set a reasonable subscription, and the service network is not determined by the Council. The TPA administrative is recommended to do so, covering appropriate coverage from service providers and required specialties. The administrator discusses prices with the service providers, and the reinsurance is left to the company without intervention from the system.

Second: The Optional Package

 The market is open for insurance companies to set and implement the optional health package in a competitive manner and has the freedom to determine the service network to include one of the public general hospitals and specialized hospitals.